Screening Out Does Little to Address ED Overcrowding

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Dear Editor:

I agree with the authors that ED overcrowding is a major barrier to providing high-quality emergency care services.¹ Overcrowding also contributes to the increasing number of ED patients who leave without being seen, and the sooner these problems are addressed, the better.

However, I was disappointed to read that the authors proposed “screening out” as a potential solution. Screening out is really a form of ED diversion. Under diversion plans, patients are triaged, and based on their triage assessment, they may receive a medical screening examination (MSE). The MSE is less comprehensive and less time-consuming than a full ED examination. Patients chosen to receive the MSE can elect to pay an additional fee for a complete evaluation if they choose. After the MSE, patients deemed as having a low level of acuity are referred to alternate sites of care with no guarantee that care actually will be delivered.

The authors note that patients who are diverted out of emergency departments are not routinely seen as planned, and this holds true for both insured and uninsured patients. Diversion schemes do little to provide the services that patients require; they simply move individuals from one location to another. These plans could be disastrous when patients fail to get the help they need, and they might be a liability for providers if patients suffer harm.

Contrary to suggestions that patients visit the emergency department out of convenience, the 2004 Emergency Department Summary of the National Hospital Ambulatory Medical Care Survey found otherwise. Of the 110 million ED visits recorded in 2004, only 12.5% were classified as non-urgent. By contrast, 13% of ED visits that year were emergent and 38% were listed as urgent, meaning that more than half of the patients needed treatment within a brief time frame. For adults older than 65 years, the number of emergent and urgent visits climbed to 63% of the total.

The overall rate of return visits and subsequent hospital admissions at the Galveston facility is likely higher than reported because patients who are screened out will simply seek care at another site. I suggest that screening out will not reduce health care expenditures but cause expenditures to rise by shifting costs to other institutions and forcing patients to pay additional out-of-pocket ED co-pays.

To propose that screening patients out of the emergency department will reduce overcrowding is like putting a bandage on a gunshot wound. Diverting patients away from the ED safety net is a potentially dangerous practice and one that I cannot endorse as a caring professional.

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Reference 

1. Nash K, Nguyen H, Tillman M. Using medical screening examinations to reduce emergency department overcrowding. J Emerg Nurs. 2009;35:109–113
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